Preoperative Assessment Pituitary Adenoma Surgery

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Acromegaly, case study, 288 diagnosis, 43, 44

magnetic resonance imaging, 4, 44

mortality, 43

treatment, anesthesia for surgery, 120, 122 dopamine agonists, 46, 184 Gamma Knife radiosurgery, 223-225,

227, 228 goals, 49 pegvisomant, 47 postoperative evaluation, 45 postoperative management following tumor removal, 182-184 radiation therapy, 47, 48, 184, 211, 212

repeat surgery, 183 somatostatin analogs, 46, 47, 184 transsphenoidal surgery, 44, 45 ACTH, see Adrenocorticotropic hormone Adrenalectomy,

Cushing's syndrome management, 67, 68

Nelson's syndrome after bilateral adrenalectomy, 68, 69 Adrenocorticotropic hormone (ACTH), adenoma, see Cushing's disease Cushing's syndrome diagnostic assay, 57, 59

nonfunctioning pituitary tumor effects, 83 AIDS, pituitary infection, 268, 269 Androgen replacement therapy, see Testosterone

Anesthesia, acromegaly, 120, 122 airway management, 123 Cushing's disease, 122 intracranial pressure elevation, 120 premedication, antibiotics, 116 corticosteroids, 115, 116, 150 sedation, 122, 123 Aneurysm, intrasellar, adenoma association, 277 clinical features, 277 imaging, 276 surgery complication, 276 Aneurysms, traumatic, 141 Appearance, coping in pituitary disease patients, 303, 304 Arachnoid cyst, course, 262 management, 263 sellar cysts, 261-263

Bilateral inferior petrosal sinus sampling

(BIPSS), Cushing's syndrome, 62, 63

BIPSS, see Bilateral inferior petrosal sinus sampling

Blood drawing, patient attitudes, 299 Bone mineral density (BMD), dopamine agonist safety, 38, 39 reduction with prolactinoma, 23 Bromocriptine, prolactinoma management,

29, 30, 32 Brucellosis, pituitary involvement, 268

Cabergoline, prolactinoma management, 29-31

CD, see Cushing's disease Cerebrospinal fluid rhinorrhea, management, 142, 179 Chondrosarcoma, clinical features, 254, 255 imaging, 255 management, 255 origins, 254 Chordoma, clinical presentation, 244 course, 242 imaging, 244 origins, 243, 244 prognosis, 244, 245 radiation therapy, 244 surgery, 244 Clonality, assays, 7

pituitary adenoma, 6-9 Computed tomography (CT), aneurysm, 276, 277 chondrosarcoma, 255 chordoma, 244 craniopharyngioma, 236 Cushing's syndrome, 61 empty sella syndrome, 264, 265 fibrous dysplasia, 253 granular cell tumors, 249 juvenile angiofibroma, 255 meningioma, 242 mucoceles, 270

nonfunctioning pituitary tumor, 81, 84 preoperative assessment, 115 radiation therapy planning, 207, 208 Rathke's cleft cyst, 257, 258 Coping, pituitary disease patients, caregiver facilitation, 307 infertility, 305, 306 job loss, 306

patient support groups, 307, 308 physical appearance, 303, 304 sense of loss, 305 strategies, 306, 307 treatment response, 304, 305

Corticotropin-releasing hormone (CRH), Cushing's syndrome, basal levels, 59 stimulation test, 58-60 Cortisol,

Cushing's syndrome diagnostic assay, 57, 63

perioperative monitoring, 176-178 primary cortisol resistance, 63, 64 replacement, see Hydrocortisone Craniopharyngioma, clinical presentation, 189, 190, 235, 236

clinical spectrum, 234, 235 imaging, 236 origins, 189, 234

postoperative management, 189, 190 prevalence, 234 prognosis, 237, 238 recurrent disease management, 238 suprasellar lesions, 235 surgery, 236, 237 CRH, see Corticotropin-releasing hormone CT, see Computed tomography Cushing's disease (CD), clinical presentation, 52 cure rate, 3

day curve test, 199, 200 diagnosis, adrenocorticotropic hormone assay,

57, 59 algorithm, 56

bilateral inferior petrosal sinus sampling, 62, 63 computed tomography, 61 corticotropin-releasing hormone, basal levels, 59 stimulation test, 58-60 cortisol assay, 57, 63 dexamethasone suppression test, 5558, 60

differential diagnosis, 59, 69 differentiating mild Cushing's syndrome from pseudo-Cushing states, 57-59 hypercortisolism, 53, 55, 57

magnetic resonance imaging, 53, 55, 61

metyrapone testing, 61 periodic Cushing's syndrome, 63 pregnant patients, 63 primary Cortisol resistance, 63, 64 epidemiology, 51 etiology, 53 pathogenesis, 52 treatment, adrenalectomy, 67, 68, 184, 187 anesthesia for surgery, 122 corticosteroid replacement therapy, 68, 187

endocrine surveillance, 185-187 etomidate, 67

Gamma Knife radiosurgery, 223, 225,

227, 228 ketoconazole, 67 metyrapone, 67 mitotane, 67

Nelson's syndrome after bilateral adrenalectomy, 68, 69 persisting disease following surgery, 186, 187

postoperative management following tumor removal, 184-187 radiation therapy, 66, 67, 187, 212 transsphenoidal surgery, 64, 65, 69, 139

types, 51

Depression, pituitary disease patients, 303 Dermoid cyst, clinical presentation, 260 course, 261 pathology, 259, 260 surgery, 261 Desmopressin, see Vasopressin Dexamethasone suppression test,

Cushing's syndrome diagnosis, 55-58, 60

Liddle test, 60 low-dose protocol, 200 overnight suppression test, 60 DI, see Diabetes insipidus

Diabetes insipidus (DI), insurance considerations, 301 sellar region pathology, 234 Disability benefits, pituitary disease patients, 302 Dopamine agonists, see also specific agonists, acromegaly management, 46 dynamic prolactin function testing, 26 mechanism of action, 32, 33 nonfunctioning pituitary tumor management, 86 oral contraceptive safety, 33 pituitary function effects, 34, 35 pregnancy safety, 38, 39 prolactinoma management, macroprolactinoma, 33-36 microprolactinoma, 32 overview, 29-32 resistance, 35 side effects, 29 withdrawal, 35, 36 Driving, pituitary disease patients, 301

Employment, pituitary disease patients,

301, 302, 306 Empty sella syndrome, definition, 263 primary syndrome, 263, 264 secondary syndrome, 264, 265 treatment, 265, 266 Endocrinologist, patient interactions, attitudes, 293

facilitation strategies, 294, 295, 297 patient views, 293

question encouragement and answers, 295, 296

Endoscopic endonasal transsphenoidal surgery, advantages, 167-169 bleeding control, 169, 170 complications, 167, 168 development, 161, 162 endoscope, 162, 169 indications, 169

nasal and paranasal anatomy, 165, 166

nasal step, 163 outcomes, 166, 167 patient positioning, 163 prospects, 170 sellar lesion extension, 166 sellar step, 164, 165 sphenoid step, 163, 164 training, 162, 169 Epidermoid cyst, incidence, 259 localization, 259 surgery, 259 Esthesio-neuroblastoma, features and management, 256 Estrogen, replacement therapy, 89, 203 Etomidate, Cushing's syndrome management, 67

Fatigue, recovered pituitary patients, 303 Fertility, pituitary disease patients, 305, 306 Fibrous dysplasia, course, 252 forms, 252 imaging, 253 management, 253, 254 pathology, 252, 253 Follicle-stimulating hormone (FSH), nonfunctioning pituitary tumor secretion, 78

postoperative management following tumor removal, 187, 188 FSH, see Follicle-stimulating hormone Fungal infection, pituitary involvement, 268

Gamma Knife radiosurgery, acromegaly, 223-225, 227, 228 conventional radiation outcome comparison, 228, 229 Cushing's disease, 223, 225, 227, 228 development, 222 indications, 223, 224 instrumentation, 222 Nelson's syndrome, 223, 227, 228 outcomes, 226-228 prolactinoma, 223, 227, 228 prospects, 229

response monitoring, 225, 226 treatment protocol and follow-up, 224, 225 Germ cell tumors, chemotherapy, 241 incidence, 238, 239 malignant tumors, 239 markers, 240 metastasis, 240, 241 radiation therapy, 241 suprasellar tumor presentation, 239, 240 surgery, 240 types, 239 GH, see Growth hormone Giant cell tumors, bone, 254 Glioma, parasellar, clinical presentation, 246 management, 246, 247 types, 245, 246 Glucagon test, 198

GnRH, see Gonadotropin-releasing hormone Gonadotropin-releasing hormone (GnRH), analogs for nonfunctioning pituitary tumor management, 87 Granular cell tumors, imaging, 249 management, 250 nomenclature, 249 origins, 249 Growth hormone (GH), see also Acromegaly, deficiency features, 193, 194 five-point day curve for status assessment, 200, 201 nonfunctioning pituitary tumor depression, 79, 83 perioperative monitoring, 177 preparations, 203

replacement therapy, 90, 91, 193, 194, 203 Gs, a subunit mutations in somatotrophinomas, 10, 11 gsp, activation in pituitary adenoma, 10, 11, 13

Hamartoma, adenohypophyseal neuronal choristoma, 248, 249

hypothalamic neuronal hamartomas, 248 nomenclature, 247 origins, 247, 248 Hardy Classification, pituitary adenomas, 116, 117

Hemangioblastoma, sellar region, 251 Histiocytosis X, see Langerhans cell histiocytosis Hydrocortisone, day curve assessment, 201 patient education, 300 perioperative management, 176 replacement therapy, 89, 191, 192, 202 Hypercortisolism, see Cushing's disease,

IGF-1, see Insulin-like growth factor-1 Injections, patient attitudes, 300 Insulin-like growth factor-1 (IGF-1), acromegaly diagnosis and monitoring, 44, 183 Insulin tolerance test (ITT), patient attitudes, 299 protocol, 197 Insurance, pituitary disease patients, 301 ITT, see Insulin tolerance test

Juvenile angiofibroma, growth effects, 255 imaging, 255 management, 256

Ketoconazole, Cushing's syndrome management, 67

Langerhans cell histiocytosis, central nervous system involvement, 276

management, 276 pathology, 275, 276 LH, see Luteinizing hormone Lipoma, sellar region, 251, 252 Luteinizing hormone (LH), nonfunctioning pituitary tumor secretion, 78

postoperative management following tumor removal, 187, 188

Lymphocytic hypophysitis, clinical presentation, 272-274 lesion pathology, 271, 272 management, 274

Magnetic resonance imaging (MRI), acromegaly, 4, 44 aneurysm, 276 chondrosarcoma, 255 chordoma, 244 craniopharyngioma, 236 Cushing's syndrome, 53, 55, 61 empty sella syndrome, 264, 265 fibrous dysplasia, 253 granular cell tumors, 249 intraoperative guidance, 143, 144 juvenile angiofibroma, 255 meningioma, 242 mucoceles, 270

nonfunctioning pituitary tumor, 81, 84, 87, 88

patient attitudes, 298, 305 pituitary apoplexy, 129 preoperative assessment, 112, 113, 115 radiation therapy planning, 207, 208 Rathke's cleft cyst, 257, 258 vision loss evaluation, 96 Menin, function, 11

pituitary adenoma mutations, 11 Meningioma, parasellar, clinical features, 241, 242 imaging, 242 incidence, 241 resection, 242 Metastasis, sellar region, 266 Metyrapone, Cushing's syndrome, management, 67 testing, 61, 201 Mineralocorticoids, replacement therapy, 202 Mitotane, Cushing's syndrome management, 67 Mortgage, pituitary disease patients, 301 MRI, see Magnetic resonance imaging Mucocele, imaging, 270

incidence, 270 management, 270, 271 pathology, 270

Nasopharyngeal carcinoma, clinical presentation, 257 incidence, 256 management, 257 Nelson's syndrome,

Gamma Knife radiosurgery, 223, 227, 228

management, 68, 69 Neurosurgeon, patient interactions, attitudes, 293 patient views, 293

question encouragement and answers, 295, 296 Nonfunctioning pituitary tumors, evaluation, computed tomography, 81, 84 hormone levels, adrenocorticotropic hormone, 83, 89

gonadal hormones, 83 growth hormone, 83 prolactin, 81, 82 thyroid hormone, 82, 83 vasopressin, 83 magnetic resonance imaging, 81, 84,

87, 88 vision, 81 hormone secretion, 78 pathophysiology, 77, 78 postoperative management following tumor removal, 188, 189 prevalence, 77 symptoms, headache, 79

macroadenoma effects, 78 pituitary hormone loss, 79-81 vision, 79 treatment, dopamine agonists, 86 gonadotropin-releasing hormone analogs, 87 observation, 84

post-therapy management, androgen replacement, 89, 90 desmopressin therapy, 91 estrogen replacement, 89 GH replacement, 90, 91 hydrocortisone, 89 imaging, 87, 88

thyroid hormone therapy, 88, 89 radiation therapy, 85, 86, 91 somatostatin analogs, 86, 87 transsphenoidal surgery, 84, 85 Nurses, patient interactions, attitudes, 293

facilitation strategies, 294, 295, 297 patient views, 294

question encouragement and answers, 295-297

Octreotide, see Somatostatin analogs Optic nerve, fiber damage symptoms, 96-98 radiation damage, 213, 214 vulnerability in surgery, 151 Oral contraceptives, safety with dopamine agonists, 33

p53, mutation in cancer, 12 Paraganglioma, sellar region, 251 Patient education, caregiver support strategies, 291, 292, 308

perspective of patient, 288 psychosocial aspects, 302-307 resources,

Internet, 289, 290-291 media, 289 medical sources, 289 patient support groups, 289, 307, 308 quality, 290 social problems, 301, 302 specialist interactions, 292-287 tests and treatments, 297-301 Pegvisomant, acromegaly management, 47 Pituitary abscess, infection sources, 267 management, 268

organisms, 267 symptoms, 267 Pituitary adenoma, see also specific adenomas, chromosomal instability, 12, 13 clonality, 6-9, 13, 14 differentiation, 4-6 endogenous trophic influences, gsp activation, 10, 11, 13 menin mutations, 11 pituitary tumor transforming gene, 11, 12

tumor suppressor gene mutations, 12 exogenous trophic influences, 9, 10 hormone receptor mutations, 10 prevalence, 1

spontaneous regression, 3, 4 tumor comparison, 2, 3 Pituitary carcinoma, postoperative management following tumor removal, 189 prevalence, 1, 189 Pituitary tumor transforming gene (PTTG), pituitary adenoma pathogenesis, 11, 12 Postoperative management, acromegaly, 182-184 airway management, 124 complications, see also specific operations, cerebrospinal fluid rhinorrhea, 179 nasal airway, 178 vision, 178, 179 craniopharyngioma, 189, 190 Cushing's disease, 184-187 discharge, 179 fluid balance, 174, 175 gonadotropin tumors, 187, 188 hormone level monitoring, cortisol, 176-178 growth hormone, 177 prolactin, 177 hormone replacement, see specific hormones location of recovery, 174 malignant tumors, 189

nonfunctioning pituitary adenoma, 188, 189

pain management, 124, 174 patient perspective, 173 prolactinoma, 182

syndrome of inappropriate antidiuretic hormone secretion, 175, 176 thyroid-stimulating hormone tumors, 188 Pregnancy,

Cushing's syndrome management, 63 prolactinoma management, 37-39 Preoperative assessment, aims of surgery, 110, 111, 131 airway management, 123, 124 clinical presentation, 109, 110 endocrine assessment, 111 imaging, 112, 113, 115 maintenance, 123, 124 nasal mucosa preparation, 123 pituitary apoplexy, 115 planning, 131

postoperative management, 124

subarachnoid drain, 123

surgical approach selection, 116, 117,

129-131 visual field evaluation, 112 Prolactin, dynamic function testing, 25, 26 hyperprolactinemia causes, 24, 25 immunoassay, 25 macroprolactin, 25

nonfunctioning pituitary tumors, effects on levels, 79, 80-82 perioperative monitoring, 177 regulation of secretion, 21, 37 stalk effect, 234 structure, 21 Prolactinoma, classification, 22 clinical features, 22, 23 diagnosis, basal serum prolactin, 27 differential diagnosis, 24, 25 imaging, 27

pituitary function tests, 27 prolactin function testing, 25, 26

Gamma Knife radiosurgery, 223, 227, 228 genetics, 22 metastasis, 22

microprolactinoma course, 22 postoperative management, 182 prevalence, 21 radiation therapy, 212, 213 treatment, algorithm, 28 dopamine agonists, macroprolactinoma, 33-36 microprolactinoma, 32 overview, 29-32 indications, 27-29 observation, 33 pregnant patients, 37-39 radiotherapy for macroprolactinoma, 36, 37

transsphenoidal surgery of microprolactinomas, 32, 33

PTTG, see Pituitary tumor transforming gene

Quinagolide, prolactinoma management, 29, 30

Radiation therapy, see also Gamma Knife radiosurgery, acromegaly management, 47, 48 biological effects, 206 cancer induction, 214, 215 central nervous system tolerance, 206, 207

chordoma, 244

Cushing's syndrome management, 66, 67

fractionation, 208 germ cell tumors, 241 goals, 205

hormonal control outcomes, acromegaly, 211, 212 Cushing's disease, 212 hormone deficiencies, 214 prolactinoma, 212, 213 intensity-modulated radiotherapy, 210 long-term management, 190, 191 macroprolactinoma, 36, 37

nonfunctioning pituitary tumor management, 85, 86, 91 patient attitudes, 298, 299 patient immobilization, 207, 208 planning, 207, 208 recommendations, 216, 217 recurrence rates, 191 side effects, 213-215 sources, 207, 222

stereotactic conformal radiotherapy, 209,

210, 215 survival outcomes, 213 timing, 215, 216 tumor control efficacy, 210 Radiology specialists, patient interactions, attitudes, 293 patient views, 293, 294 question encouragement and answers, 295, 296 Rathke's cleft cyst, imaging, 257, 258 origins, 257

surgery and outcomes, 258, 259

Sarcoidosis, clinical features, 274, 275 imaging, 275 management, 275 tissue distribution, 274 Schwannoma, sellar region, 250, 251 Sella turcica, anatomy, 231, 232 Somatostatin analogs, acromegaly management, 46, 47 mechanism of action, 46 nonfunctioning pituitary tumor management, 86, 87 side effects, 47

thyrotroph adenoma resistance development, 5

types, 46 Surgery, see Anesthesia; Endoscopic endonasal transsphenoidal surgery; Postoperative management; Preoperative assessment; Transcranial surgery; Transsphenoidal surgery

Syndrome of inappropriate antidiuretic hormone secretion, postoperative management, 175, 176

Syphilis, pituitary involvement, 268

Testosterone, preparations, 202, 203 replacement therapy, 89, 90, 192, 193, 203 Thyroid hormone, nonfunctioning pituitary tumor depression, 82, 83 replacement therapy, 88, 89, 192, 202 Thyroid-stimulating hormone (TSH), adenoma prevalence, 188 nonfunctioning pituitary tumor depression, 80 postoperative management following tumor removal, 188 Thyrotropin-releasing hormone (TRH), dynamic prolactin function testing, 26

Transcranial surgery, see also Anesthesia;

Postoperative management; Preoperative assessment, approaches, table, 154, 155 cerebrospinal fluid drainage, 150, 151 craniopharyngiomas, 148 indications, abnormal skull-base anatomy, 149 firm fibrous tumor, 149, 150 fossa abnormalities, 150 large suprasellar tumors, 148, 149 recurrent tumors with visual failure, 149

midline subfrontal approach, 156 oblique subfrontal approach, advantages, 151, 152 development, 151 flap preparation, 152 patient positioning, 152 tumor resection, 153, 155 Walter Dandy maneuver, 155 optic nerve vulnerability, 151 pterional approach, 155 steroid premedication, 150 subtemporal approach, 157

transcallosal approach, 158 transcranial epidural approach, 156, 157 transglabellar approach, 156 translamina terminalis approach, 157 transtemporal approach, 157 Transsphenoidal surgery, see also

Anesthesia; Postoperative management; Preoperative assessment, advances, 143, 144 advantages, 131, 147 cerebrospinal fluid leak management, 139

closure, 139, 140 complications, brainstem injury, 142 cavernous sinus injury, 142 cerebrospinal fluid rhinorrhea, 142 hypothalamic injury, 140 iatrogenic hypopituitarism, 142 nasal complications, 142, 143 vascular complications, 140-142 visual damage, 140 contraindications, 128-130 Cushing's syndrome management, 64,

65, 69, 139 endonasal approach, 134, 135 endoscopic surgery, see Endoscopic endonasal transsphenoidal surgery guidance systems, 132, 133, 135, 143, 144

indications, 127, 128, 147 margin inspection, 137, 138 microadenomas, 138, 139 microprolactinomas, 32, 33 nonfunctioning pituitary tumor management, 84, 85 patient positioning, 132 repeat surgery, 144 sellar floor dissection, 135 sublabial approach, 134 transnasal septal pushover approach, 134

tumor removal, 136, 137 TRH, see Thyrotropin-releasing hormone TSH, see Thyroid-stimulating hormone

Tuberculosis, pituitary involvement, 268

Vasopressin, desmopressin replacement therapy, 91, 204

nonfunctioning pituitary tumor depression, 80, 83 postoperative management with desmopressin, 174, 175 Vision, pituitary tumor effects, anatomy, 95, 96 evaluation, 104 acuity, 99 color vision, 100 cranial nerves, 104, 105 visual fields, 100, 102, 104 follow-up, 106 lesion evaluation, 96

nonfunctioning pituitary tumors, assessment, 81 symptoms, 79 preoperative assessment, 112 prevalence of vision loss, 95 recovery following surgical decompression, 105, 106 symptoms, neighborhood symptoms, 98, 99 optic nerve fiber damage, 96-98 positive visual symptoms, 98 transsphenoidal surgery complications, 140

Water deprivation test, interpretation, 199 patient attitudes, 299 procedure, 198 sampling, 198, 199

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